APPENDIX - X

BaNx or eaRODA
(CLAZM TO TNE ASGETS OF THE DECEASED}
To
The Branch /'4anager,
Bank of Baroda,

ranch,
Sir,

Ra : Claim for payment / delivery of the balance /assets to the eetate of

late Chrl / Smt / Kum

T. In the matter of the assets of ..................................,.........................

t Full name of the deceased depositor/locker holder )
2 (a ) Full Residential address :

(d) Law by which the deceased was governed : Hlndu Succession Act,1956 /
Indlan Succession Act / Nohammedan Law / Others.
3.Date of Death.....................................Proof*.-:::.::-::::::.

( ” Proof I.e. Death Certificate / certified extract of death register or a certlflcate of

the village head man to be enclosed).

4. (a) Details of the amount and / Or securities claimed :

Sr. Nature of the f eu

No Deposit/5ecurltles ,: . ge of Remarks
Type of Account No. Rupees / palse Dtbum.
Deposit Receipt No.
/ Securttles
1

#VaIuatIon Certificate Issued by valuer to be enclosed.

1
( b ) Agalnst whlch the out:standing dlrect and indirect Ilabllitles :

Sr.No. Nature of Account No. Amount of Remarks

liability llablllty
1.

Note : If any account and /or deposit Is In the Jolnt names, state the names of all
jolnt holders and condltlonal clause If any , regarding payment.

5. (a) Name/s of Clalmant:/’s:

Sr.No Name/ s Occupation Age Relatlonshlp wlth the

and address deceased.
1.
2

(b) Del:alls of Survivors :

Sr.No Name/ s Occupation Age Relationship with the

and address deceased.
1.

In case of joint Hlndu family, names of brothers / sisters / should be glven.

6. (a ) Are the deposit receipts / pass book / relating to amounts / key of the locker,
In possession of the clalmant/s .............................. ........ ............. ... .. ... ...........

If not, Its whereabouts ? .................................................................................

(b) Details of Deposit Receipts / SB pass book / Keys etc. submltted.

7. (a) Has the deceased left any w\\I • YES / NO

? (please specify wlth brlef facts )

(b ) Has any probate / better of admlnlstration or succession certificate

to the estate of the deceased has been obtained (please specify wlth brief facts ]
' YES / NO

8. (a) Dld the deceased belong to the 3olnt Hlndu Family ? : YES / NO

(b) If so who are the adult members of the family ?

Sr.No Name/ s Occupation Age Relatlonshlp wlth the

and address deceased.

2
 (c) Is the property clalmed self acquired ? .........................................................

(b) Proof of cIalmant:is title (Furnish documen\:s In orlglnal for reference and
return)

9. Are the claimant / s prepared to indemnify the bank against any future adverse
claims 7

If so furnish the name/s, address ,occupation and worth, of sureties who wlll join In
the execution of' Bond.

1.Name ..................................................... 2.Name..................................

Address......................................................... Address................................

...... ....... .......... ................................................. ... . ........................................ ..............................

. ...................................

Occupadon ................ Occupation..............................

Estimated Worth Rs..................................... Estlmated worth Rs...................

Annual Income :

Value of Immovable Property.

a) where they are situated ?
b) Whether property Is In Own name / Joint names
c) Whether the property is
• Encumbered
• Unencumbered
• Partially encumbered.

Note:
( This need not be filled up If a probate and /or letter of Administration or Successlon
Certificate has been produced)
I/We hereby declare the necessary particulars concerning my/ our above clalm
against the Bank in respect of the estate of the above named deceased. I/We
shall furnlsh any further Information that the Bank may desire in this regard. I/We
declare that the above mentioned particulars furnished by me /us are true to my
/our knowledge and belief and agree that 1/We shall be Jointly and severally liable to
you for any misrepresentation or suppression of material facts and Indemnify you
against any demand made as you by any other person claiming under on In the rlght
of the above mentioned deceased for or In respect of money / shares clalmed by
me/us hereln.
Place : Signature of claimant/ s
Date : 1.

3.

1
 INSTRUCTIONS FOR FILLING -UP THE CLAZM FORPI

1. All the columns should be filled In with speclñc answers.

2. The form should be slgned by all the claImant/s /helr/s of the deceased.
3. If there are mlnor heir/s / claimant/s, they should be represented by their
guardlan.
4.A consent letter/s signed by other claimants and surety/les let:ter/s certifying to
the correctness of the particulars fumlshed by the claimant/s In the form should be
sent along with the clalm form.

FOR OFFECE USE

FOR BRANCH t4ANAGER

We have verined the partlcuTars mentloned In clalm form by the claimant’s Shri /
Smt / Kum....................................... and recommend that the balance In the deceased
account of Shri / smt --------------
may be pald against the stamped lndemnlt:y Bond signed by.................................and
the surety/ les vlz.

Balance In account Rs.---------“--------”

+Interest Rs........................................
= Total Amount

Recommended by Authorized to pay By

Department In-charge
Branch Manager

Date :

NB . If the payment of the balance falls wlthln the discretionary powers of the
branch, they should sign the authorlt:y portlon.

FORREGIONALOFFICE USE
We hereby authorize you to pay the balance of Rs---------------------plus Interest
Rs.--------------- of the deceased Shri / Smt------------------------------------------------to
Shri/Smt / Kum -----------------------------against our usual stamped Indemnity bond
signed by the cIalmant/s
---and others as recommended by the branch and TWO suretles.

Date :............................. Regional I Manager

1
APPENDIX - XX

SURETY LETTER

To,
The Branch Manager,

Bank of Baroda,

................ ... Branch.

Re;. Claim to the balance In the------------------------------accounts standing In the

name of late .....................................................................,..............

I know late Shri/Smt .....................................................,.....................and the members

of his /her family well for the past -------------- years. He / She passed away
on .............................. . He / Sha is survived by the under mentioned persons as
Els / her helrs.

Sr.No Name/ s Age Relatlonshlp with the

deceased.
1.

3.
4.

I have gone through the claim form to which this letter Is appended and I
hereby cerLlfy that the particulars furnished by the claimant/s in the claim fbrm
ara true and correct to the best of my knowledge and information.

Yours faithfully,

Place :
Date :

t
APPENDIX - XIS

(CONSENT LETTER }
( TO BE SIGNED BY OTHER CLAIMANTS)

FRON :.................................
To,
The Branch Manager,
Bank of Baroda,
- - ----- -------- branch,

near Sir,
be; Claim to the balance In the---------------------------accounts standln9 In the
name of late ....................................................................................
I am writing thls consent let:ter to Inform you that my ----------------------------
--- 'nature of relationship) ShiI / Smt........................................... Passed away
on.......................... leaving behind hlm / her heirs the under mentioned persons.

Sr.No Name/ s Aqe Relationship with the

deceased.

2.
3.

The amounts claimed under the above deposlt:is account forms are part of the
assets of the deceased .I am also entitled to a share In hls/ her assets .

I hereby declare that I have no objection to the entire balance In the accDunts
belng pald to my ............. ........... ........... ................ ..........

1, therefore , accord my consent to the balance In the accounts belng pald to

him / her . I further state that the discharge glven by the said Shrl/
Smt.................................................................. In respect of the sald accounts /
Deposlts shall be as effective as If the same 1s glven to me and binding on me.

Place : Yours faithfully,

Date :

1
APPENDIX V3Z

LETTER OF INDEMNITY

In respectofpaymentofbalancein depostaccountsofdeceased persons

(To be stamped as an agreement)
The Branch ManageF Place :
Bank of Baroda Date :

WHEREAS Mr/Mrs/Mlss ( name of the deceased person) of

(address of the deceased person) had at the time of his/ her
death to his/her credlC a sum of Rupees (balance In the account
as on the date of death) whlch including Interest upto (date of
repayment} amounts to Rs. (amount now belng repaid) In
(nature of account) account:/s wlth the Bank of Baroda,
branch, (hereinafter referred to as "the sald Bank").

ANDWHEREAS (names of the persons clalmlng repayment)

of (address) (hereinafter
referred to as “the said clalmanVs") and have represented to the
said Bank that the said claimant’s Is/are entitled to have the sald sum pald to the
said claimant/s and have accordingly requested the said Bank to pay the sald sum to
the said claimant:/s.

AND WHEREAS the sald claimant/s and Nr/Plrs/Miss (names of the

surety/les) of (address of surety/les)
have agreed to Indemnify the sald Bank In respect of such payment.

NOW IN CONSIDERATION of the premises we, (name/s of claimant/s)

and (name/s of surety/les)
for ourselves and our respective heirs, executors and administrators jolntly and
severally agree and undertake that the said Bank, Its successors and asslgns and Its
Managers, Agents, Officers and Servants, and thelr respective estates and effects are
and shall from tlme to tlme and at all times hereafter be kept safe and saved
harmless and Indemnified for and In respect of such payment and against all actions,
losses, costs, charges, expenses and demands whatsoever In respect of the said
payment.

Yours falthfully,

(To be slgned by the clalmant/s and surety/les)